HIPAA EDI Acknowledgements & Error Reporting

Transcription

1 HIPAA EDI Acknowledgements & Error Reporting HIPAA Summit West II March 13, 2002 San Francisco, CA Presented by Rachel Foerster & Associates, Ltd. Beach Park, IL Fax: Course HC Discussion Topics EDI Envelopes and how they relate to EDI acknowledgements The 4 Kinds of EDI acknowledgements Each acknowledgement s purpose When to use each acknowledgment Issues for error reporting and acknowledging for HIPAA EDI transactions 2 reserved. ( 1

2 Transmission Life Cycle of an EDI Document The processes an EDI document passes through on its journey from the sender to the receiver s application system 3 EDI Envelopes Needed to specify Recipient Sender Keep contents intact Support auditing & tracking Provide other critical details 4 reserved. ( 2

3 Three Different EDI Envelopes Document Department Company = Transaction Set = Functional Group = Interchange Adjudication Community Hospital Small Town, IL Big Payer Any Town, IL Claims ISA/IEA ST/SE GS/GE 5 Interchange Receipt Notification Interchange Health Care Provider Payer/Health Plan Interchange Acknowledgment (TA1) I got it! 6 reserved. ( 3

4 TA1 Interchange Acknowledgment Purpose Reports the status of the interchange envelope only by the receiver The successful receipt of the interchange The results of processing the interchange envelope Very Similar to a Certified Mail Return Receipt 7 Using the TA1 Use is by trading partner agreement HIPAA neither mandates or prohibits TA1 is a single segment Transmitted without the GS/GE envelope Can be included in an interchange with other functional groups and transactions Is not acknowledged by the receiver Reports status of the interchange envelope only Not used to report the status of the functional groups and transaction sets in the interchange 8 reserved. ( 4

5 Functional Group Acknowledgement Interchange ISA/IEA Health Care Provider Adjudication Payer/Health Plan GS/GE Functional Acknowledgment (TS997) Claims ST/SE I got it, opened the envelopes, and the contents were ok/not ok Functional Acknowledgment Transaction Set Purpose To indicate the results of the syntactical analysis of Transaction sets Functional groups Verify and report compliance with the standard Acknowledges receipt of an interchange Reports acceptance/rejection of one or more Functional groups Transactions Does not cover Semantic meaning of the information in the transaction sets Compliance with the HIPAA implementation guide DOES NOT CONFIRM APPLICATION PROCESSING 10 reserved. ( 5

6 Using the 997 Functional Acknowledgment Do not acknowledge a 997 FA 997 FA should not be sent to report errors in a previous Functional Acknowledgment Functional Group Header Segment (GS) used to start the envelope for the 997 FA Application sender s code and application receiver s code from the functional group being acknowledged are exchanged one acknowledgment functional group responds to only those functional groups from one application receiver s code to one application sender s code Only one Functional Acknowledgment Transaction Set per acknowledged functional group 11 The 4 Levels of Acknowledgements & Notifications in Health Care Community Hospital Small Town, IL Big Payer Any Town, IL ISA/IEA Adjudication Claims GS/GE ST/SE 12 reserved. ( 6

7 HIPAA IG Compliance Notification Interchange ISA/IEA Health Care Provider Payer/Health Plan HIPAA IG Compliance Notification (TS824) Application Acknowledgment Application Advice Transaction Set Purpose Report the results of an application system's data content edits of transaction sets Results can be reported at the functional group and transaction set level Designed to accommodate reporting the acceptance, rejection or acceptance with change of any transaction set Should not be used in place of a transaction set designed as a specific response to another transaction set e.g., 270/ / / reserved. ( 7

8 Using the 824 Application Advice Transaction Set An implementation guide under development by X12N/TG8 SPWG1 for reporting Semantic compliance of a transaction against HIPAA implementation guide Other insurance transactions Syntax compliance against an implementation guide NOT A HIPAA MANDATED TRANSACTION 15 Syntax vs Semantic Syntax: HIPAA IG compliance reported via 997 Valid code Alphanumeric Datatype 16 reserved. ( 8

9 Syntax vs Semantic Semantic: HIPAA IG compliance reported via 824 Valid Date Format 17 Processing the TA1 & 997 Acknowledgements EDI Software should create & process TA1 & 997 Trading partners must agree on use Recommend policy of always sending a 997 FA Report to lowest level, i.e., data element Establish elapsed time for expected receipt Determine procedures for non-receipt 18 reserved. ( 9

10 Processing the 824 IG Compliance Acknowledgement EDI software available today doesn t automatically create the 824 Trading partners must still agree on use Establish elapsed time for expected receipt Determine procedures for non-receipt No recommended implementation guide available for HIPAA transactions 19 Sufficient Control & Auditing Transaction cycle not complete if no application response received Sufficient control & auditing provides all the information needed to detect and resolve problems TA1 advises receipt of interchange 997 advises acceptance/rejection of functional groups & transactions 824 Application Advice advises compliance/non-compliance of transaction with HIPAA IG Application response transaction reports results of application system edits and acceptance/rejection of business data 20 reserved. ( 10

11 Other Challenges Tracking interchanges through multiple intermediaries TA3 can track an interchange through clearinghouses Not in the HIPAA implementation guides No common industry accepted business practice for tracking & auditing electronic messages Some clearinghouses do not support the X12/EDI controls Use of Interchange sender/receiver Ids Use of TA1/ A Complicated Model: Single Clearinghouse Interchange Interchange Clearinghouse Interchange Acknowledgment (TA1) Functional Acknowledgment (TS997) Application Acknowledgments Interchange Acknowledgment (TA1) Functional Acknowledgment (TS997) Application Acknowledgments 22 reserved. ( 11

12 A Complex Model: Dual Clearinghouse Interchange Interchange Clearinghouse Clearinghouse Interchange Acknowledgment (TA1) Functional Acknowledgment (TS997) Application Acknowledgments 23 TA3 Interchange Delivery Notice Purpose Exchanged between service request handlers to inform the sending service request handler of actions taken on the interchange by the receiving service request handler Reports the delivery and the retrieval of the interchange Reports the unsuccessful delivery or retrieval of the interchange and identifies the error condition Not described in HIPAA Guides No industry-accepted business use 24 reserved. ( 12

13 Use of the TA3 Interchange Delivery Notice Not described in HIPAA Guides No industry-accepted business use 25 What s Needed A well-defined model for the Electronic message exchange business process Required business signals for Acknowledgments Exceptions Routing, auditing & tracking of HIPAA transactions Agreement to use sufficient controls & acknowledgments 26 reserved. ( 13

14 Contact Information 27 reserved. ( 14